2019 CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST - Starting January 1, 2019 - Cigna Health and Life Insurance Company
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Cigna Health and Life Insurance Company 2019 CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST Starting January 1, 2019 924124 12/18 © 2018 Cigna
Table of Contents
Getting started
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Specialty medications 30
Prescription drug list FAQs 32
2019 Exclusions and Limitations 34
View your drug list online
The myCigna® website – Once you’re registered, log in and select Estimate
Health Care Costs, then select Get drug costs.
Cigna.com/druglist – Select your state from the drop down menu, then choose your search
method. You can either search for a medication name or view the full drug list.
Questions? – Call the toll-free number on the back of your Cigna ID card, or 866.494.2111.
We’re here to help.
* Drug list originally created: 10/21/2013 Last updated: 08/01/2018 Next planned update: 08/01/19
2Your prescription drug list
This document shows the prescription medications covered on the 2019 Cigna Rx Essential Prescription Drug List as
of January 1, 2019.1 All of these medications are approved by the U.S. Food and Drug Administration (FDA).
Medications are listed alphabetically by medication name. If you don’t see a specific medication on this list, please
check myCigna.com to view the most current list of medications your plan covers.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example. It may not show
how these medications are actually covered on the 2019 Cigna Rx Essential Prescription Drug List.
Medications are listed in alphabetical
order
DRUG NAME Tier NOTES (PA, ST, QL, AGE)
8-MOP 4
ABACAVIR 2
ABACAVIR-LAMIVUDINE 2 Tier (cost-share level) gives you an
idea of how much you may pay for
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2
a medication
ABSORICA 4 QL
ACAMPROSATE CALCIUM 2
ACARBOSE 2
ACEBUTOLOL HCL 2
ACETAMIN-CAFF-DIHYDROCOD 320.5 2
ACETAMINOPHEN-CODEINE 2
ACETASOL HC 2
ACETAZOLAMIDE 2
ACETIC ACID 2 Medications that have extra coverage
requirements will have an abbreviation
ACETIC ACID-ALUMINUM 2
in the Notes section
ACETYLCYSTEINE 10% VIAL 2
ACETYLCYSTEINE 20% VIAL 2
ACITRETIN 2
ACYCLOVIR 200 MG CAPSULE 1
ACYCLOVIR 200 MG/5 ML SUSP 2
ACYCLOVIR 400 MG TABLET 2
ACYCLOVIR 5% OINTMENT 2
ACYCLOVIR 800 MG TABLET 2
ADAPALENE 2 AGE
This chart is just a sample. It may not show how these medications are actually covered on the 2019 Cigna Rx Essential Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price
you’ll pay to fill the prescription.
Tier 1 – Preferred Generic Medications. This tier typically includes preferred (Lower-cost medication) $
generic medications. These medications have the same strength, and active
ingredients as brand name medications, but often cost much less. Preferred
generic medications are covered at your plan’s lowest cost share.
Tier 2 – Generic Medications. This tier typically includes most generic (Medium-cost medication) $$
medications and some low cost brand name medications. Generic
medications have the same strength and active ingredients as brand name
medications, but often cost much less.
Tier 3 – Preferred Brand Medications. This tier typically includes preferred (Higher-cost medication) $$$
brand name medications and some high cost generic medications.
Tier 4 – Non-Preferred Medications. This tier typically includes non- $$$$
preferred brand name medications and some high cost generic medications.
Tier 5 – Specialty and Other High Cost Medications. This tier typically $$$$$
includes Specialty medications and high cost generic and brand
name medications.
Abbreviations next to medications
Some medications on your drug list have extra requirements before your plan will cover them. This helps to make
sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right
situation. These medications will have an abbreviation next to them in the Notes column in the drug list. Here’s
what each of the abbreviations mean.
PA
Prior Authorization – Cigna will review information provided by your doctor to make sure you
meet coverage guidelines for the medication. If approved, your plan will cover the medication.
ST tep Therapy – Step Therapy is a prior authorization program that requires you to try other
S
medications available to treat the same condition before the medication with the “ST” is covered.
QL uantity Limits – For some medications, your plan will only cover up to a certain amount over a
Q
certain length of time. For example, 30mg per day for 30 days. Your plan will only cover a larger
amount if your doctor requests and receives approval from Cigna.
AGE ge Requirements – You must be within a specific age range for your plan to cover the
A
medication.
LDD imited Distribution Drugs are medications that are only available at specific pharmacies in the
L
United States because of manufacturer restrictions.
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are listed on page 30
Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid
arthritis. In this drug list, specialty medications are listed on page 30. Specialty medications are limited to a 30-day
supply. Please log in to the myCigna website or app, or check your plan materials, to learn more about how your
plan covers specialty medications.
4Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan (or benefit)
exclusion.” This means that your plan doesn’t cover any prescription medications in the drug class or to treat the
specific condition. There’s also no option to receive coverage through a medication review process. Please log in
to the myCigna website or app, or check your plan materials, to find out if your plan excludes your medication
from coverage.
How to find your medication
Find your medication using the alphabetical list below. Then go to that page to see how your plan covers
the medication.
Medication name Page
A–B 6–9
C–D 9–13
E–G 13–16
H–J 16–17
K–L 17–19
M–N 19–22
0–P 22–25
Q–S 25–26
T–U 26–28
V–Z 28–29
52019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
8-MOP 4 ALENDRONATE SODIUM 35 MG TAB 1
ABACAVIR 2 ALENDRONATE SODIUM 40 MG TAB 1
ABACAVIR-LAMIVUDINE 2 ALENDRONATE SODIUM 5 MG TABLET 1
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2 ALENDRONATE SODIUM 70 MG TAB 2
ACAMPROSATE CALCIUM 3 ALFUZOSIN HCL ER 2
ACARBOSE 2 ALINIA 4
ACEBUTOLOL HCL 2 ALLOPURINOL 1
ACETAMIN-CAFF-DIHYDROCOD 320.5 2 ALMOTRIPTAN MALATE 2 QL
ACETAMINOPHEN-CODEINE 2 ALOGLIPTIN 2 QL
ACETAZOLAMIDE 2 ALOGLIPTIN-METFORMIN 2 QL
ACETIC ACID 2 ALOGLIPTIN-PIOGLITAZONE 2 QL
ACETIC ACID-ALUMINUM 2 ALOSETRON HCL 4
ACETYLCYSTEINE 10% VIAL 2 ALPRAZOLAM 2
ACETYLCYSTEINE 20% VIAL 2 ALPRAZOLAM ER 2
ACITRETIN 4 ALPRAZOLAM INTENSOL 2
ACYCLOVIR 200 MG CAPSULE 1 ALPRAZOLAM ODT 2
ACYCLOVIR 200 MG/5 ML SUSP 2 ALPRAZOLAM XR 2
ACYCLOVIR 400 MG TABLET 2 ALTACAINE 2
ACYCLOVIR 5% OINTMENT 2 ALTAVERA 1
ACYCLOVIR 800 MG TABLET 2 ALYACEN 1
ADAPALENE 2 AGE AMABELZ 2
ADEFOVIR DIPIVOXIL 2 AMANTADINE 2
ADVAIR DISKUS 3 AMCINONIDE 2
ADVAIR HFA 3 AMETHIA 1
AFEDITAB CR 2 AMETHIA LO 1
AFTERA 4 AMETHYST 1
AK-POLY-BAC 2 AMILORIDE HCL 2
ALA-CORT 2.5% CREAM 1 AMILORIDE-HYDROCHLOROTHIAZIDE 2
ALBENZA 4 AMIODARONE HCL 100 MG TABLET 2
ALBUTEROL 2.5 MG/0.5 ML SOL 2 AMIODARONE HCL 200 MG TABLET 2
ALBUTEROL 5 MG/ML SOLUTION 2 AMIODARONE HCL 400 MG TABLET 2
ALBUTEROL SUL 0.63 MG/3 ML SOL 2 AMITIZA 4
ALBUTEROL SUL 1.25 MG/3 ML SOL 2 AMITRIPTYLINE HCL 1
ALBUTEROL SUL 2.5 MG/3 ML SOLN 1 AMLODIPINE BESYLATE 2
ALBUTEROL SULF 2 MG/5 ML SYRUP 2 AMLODIPINE BESYLATE-BENAZEPRIL 2
ALBUTEROL SULFATE 2 MG TAB 2 AMLODIPINE-ATORVASTATIN 2
ALBUTEROL SULFATE 4 MG TAB 2 AMLODIPINE-OLMESARTAN 2
ALBUTEROL SULFATE ER 4 MG TAB 2 AMLODIPINE-VALSARTAN 2
ALBUTEROL SULFATE ER 8 MG TAB 2 AMLODIPINE-VALSARTAN-HCTZ 2
ALCLOMETASONE DIPROPIONATE 2 AMMONIUM LACTATE 12% CREAM 2
ALCOHOL PADS 3 AMMONIUM LACTATE 12% LOTION 2
ALCOHOL PREP PADS 3 AMNESTEEM 2 QL
ALCOHOL PREP SWABS 3 AMOXAPINE 2
ALCOHOL SWAB 3 AMOX-CLAV 200-28.5 MG TAB CHEW 2
ALCOHOL SWABS 3 AMOX-CLAV 200-28.5 MG/5 ML SUS 2
ALCOHOL WIPES 3 AMOX-CLAV 250-125 MG TABLET 2
ALENDRONATE SOD 70 MG/75 ML 2 AMOX-CLAV 250-62.5 MG/5 ML SUS 2
ALENDRONATE SODIUM 10 MG TAB 1 AMOX-CLAV 400-57 MG TAB CHEW 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
62019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
AMOX-CLAV 400-57 MG/5 ML SUSP 2 AZITHROMYCIN 600 MG TABLET 2
AMOX-CLAV 500-125 MG TABLET 2 AZOPT 3
AMOX-CLAV 600-42.9 MG/5 ML SUS 2 AZUPHEN MB 2
AMOX-CLAV 875-125 MG TABLET 2 AZURETTE 1
AMOXICILLIN 1 BACITRACIN 500 UNIT/GM OPHTH 2
AMOXICILLIN-CLAVULANATE POT ER 2 BACITRACIN-POLYMYXIN EYE OINT 2
AMPICILLIN TRIHYDRATE 2 BACLOFEN 10 MG TABLET 1
ANAGRELIDE HCL 2 BACLOFEN 20 MG TABLET 1
ANASTROZOLE 2 BACLOFEN 5 MG TABLET 2
ANDROXY 2 BAL-CARE DHA 1
ANORO ELLIPTA 3 BALCOLTRA 4
ANUCORT-HC 2 BALSALAZIDE DISODIUM 2
APEXICON E 2 BALZIVA 1
APRACLONIDINE HCL 2 BANZEL 4 QL
APREPITANT 2 QL BASAGLAR KWIKPEN U-100 3
APRI 1 BD 3 ML SYRINGE 18GX1-1/2" 3
APRISO 3 BD 3 ML SYRINGE 20GX1-1/2" 3
APTIVUS 3 BD 3 ML SYRINGE 25GX1" 3
ARANELLE 1 BD 3 ML SYRINGE 25GX1-1/2" 3
ARBINOXA 2 BD 3 ML SYRINGE WITH NEEDLE 3
ARIPIPRAZOLE 2 BD AUTO INJECTOR 3
ARIPIPRAZOLE ODT 2 BD AUTOSHIELD DUO NDL 5MMX30G 3
ARMODAFINIL 2 PA BD AUTOSHIELD NEEDLE 5MMX29G 3
ARMOUR THYROID 2 BD AUTOSHIELD NEEDLE 8MMX29G 3
ARNUITY ELLIPTA 3 BD BLUNT NEEDLE 18GX1-1/2" 3
ASA-BUTALB-CAFFEINE-CODEINE 2 BD ECLIPSE 30GX1/2" SYRINGE 3
ASCOMP WITH CODEINE 2 BD ECLIPSE LUER-LOK SYR 3 ML 3
ASHLYNA 1 BD ECLIPSE NEEDLE 18GX1 1/2" 3
ASPIRIN-CAFFEINE-DIHYDROCODEIN 2 BD ECLIPSE NEEDLE 21GX1" 3
ASPIRIN-DIPYRIDAMOLE ER 2 BD ECLIPSE NEEDLE 22GX1" 3
ATAZANAVIR SULFATE 2 BD ECLIPSE NEEDLE 23GX1" 3
ATENOLOL 1 BD ECLIPSE NEEDLE 25GX1" 3
ATENOLOL-CHLORTHALIDONE 1 BD ECLIPSE NEEDLE 25GX1.5" 3
ATORVASTATIN CALCIUM 2 BD ECLIPSE NEEDLE 25GX5/8" 3
ATOVAQUONE 2 BD ECLIPSE NEEDLE 27GX1/2" 3
ATOVAQUONE-PROGUANIL HCL 2 BD ECLIPSE NEEDLE 30GX1/2" 3
ATRIPLA 3 BD ECLIPSE NEEDLES 21GX1.5" 3
ATROPINE 1% EYE DROPS 2 BD FILTER NEEDLE 3
ATROPINE 1% EYE OINTMENT 2 BD INS SYR 0.3 ML 8MMX31G(1/2) 3
AUBRA 1 BD INS SYR U-500 1/2ML 6MMX31G 3
AVIANE 1 BD INS SYR UF 0.3ML 12.7MMX30G 3
AZATHIOPRINE 2 BD INS SYR UF 0.5ML 12.7MMX30G 3
AZELASTINE HCL 2 BD INS SYRN UF 1 ML 12.7MMX30G 3
AZITHROMYCIN 1 GM PWD PACKET 2 BD INS SYRNG 0.3 ML 29GX12.7MM 3
AZITHROMYCIN 100 MG/5 ML SUSP 2 BD INS SYRNG 0.5 ML 29GX12.7MM 3
AZITHROMYCIN 200 MG/5 ML SUSP 2 BD INS SYRNG UF 0.3 ML 8MMX31G 3
AZITHROMYCIN 250 MG TABLET 2 BD INS SYRNG UF 0.5 ML 8MMX31G 3
AZITHROMYCIN 500 MG TABLET 2 BD INSUL SYR 0.3 ML 31GX15/64" 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
72019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
BD INSUL SYR 0.5 ML 31GX15/64" 3 BD NEEDLES 16GX1" 3
BD INSULIN SYR 0.3 ML 28GX1/2" 3 BD NEEDLES 16GX1.5" 3
BD INSULIN SYR 0.3 ML 29GX1/2" 3 BD NEEDLES 18GX1" 3
BD INSULIN SYR 0.3 ML 31GX5/16 3 BD NEEDLES 18GX1.5" 3
BD INSULIN SYR 0.3 ML 8MMX31G 3 BD NEEDLES 19GX1" 3
BD INSULIN SYR 0.5 ML 28GX1/2" 3 BD NEEDLES 19GX1.5" 3
BD INSULIN SYR 0.5 ML 29GX1/2" 3 BD NEEDLES 20GX1" 3
BD INSULIN SYR 0.5 ML 30GX1/2" 3 BD NEEDLES 20GX1.5" 3
BD INSULIN SYR 0.5 ML 8MMX31G 3 BD NEEDLES 21GX1" 3
BD INSULIN SYR 0.5ML 31GX5/16" 3 BD NEEDLES 21GX1.5" 3
BD INSULIN SYR 1 ML 12.7MMX30G 3 BD NEEDLES 21GX2" 3
BD INSULIN SYR 1 ML 25GX1" 3 BD NEEDLES 22GX1" 3
BD INSULIN SYR 1 ML 25GX5/8" 3 BD NEEDLES 22GX1.5" 3
BD INSULIN SYR 1 ML 26GX1/2" 3 BD NEEDLES 23GX0.75" 3
BD INSULIN SYR 1 ML 27GX12.7MM 3 BD NEEDLES 23GX1.25" 3
BD INSULIN SYR 1 ML 27GX5/8" 3 BD NEEDLES 25GX0.625" 3
BD INSULIN SYR 1 ML 28GX1/2" 3 BD NEEDLES 25GX0.875" 3
BD INSULIN SYR 1 ML 29GX1/2" 3 BD NEEDLES 25GX1.5" 3
BD INSULIN SYR 1 ML 29GX12.7MM 3 BD NEEDLES 26GX0.375" 3
BD INSULIN SYR 1 ML 30GX1/2" 3 BD NEEDLES 26GX0.5" 3
BD INSULIN SYR 1 ML 31GX15/64" 3 BD NEEDLES 27GX0.5" 3
BD INSULIN SYR 1 ML 31GX5/16" 3 BD NEEDLES 27GX1X1.25" 3
BD INSULIN SYR 1 ML 8MMX31G 3 BD NEEDLES 30GX0.5" 3
BD INSULIN SYR UF 1 ML 8MMX31G 3 BD NEEDLES 30GX1" 3
BD INSULIN SYRINGE 1 ML 3 BD NOKOR ADMIX NEEDLE 18GX1.5" 3
BD INSULIN U100-3/10 ML SYR 3 BD NOKOR NEEDLE 16GX1" 3
BD INTEGRA NEEDLE 25G X 5/8" 3 BD NOKOR NEEDLE 18GX1" 3
BD INTEGRA RETRA NEEDLE 23GX1" 3 BD PEN NEEDLE 29GX1/2" 3
BD INTEGRA SYR 1 ML 29GX1/2" 3 BD PRECISIONGLI 27GX1-1/2" NDL 3
BD INTEGRA SYR 3 ML 21GX1 1/2" 3 BD PRECISIONGLIDE 3 ML 22GX3/4 3
BD LUER-LOK SYR 3 ML 25GX5/8" 3 BD PRECISIONGLIDE NEEDLE 25G 3
BD LUER-LOK SYRINGE 1 ML 3 BD SAFETGLD INS 0.3 ML 8MMX31G 3
BD MAGNI-GUIDE MAGNIFIER 3 BD SAFETGLD INS 0.3ML 13MMX29G 3
BD MEDSAVER SYRINGE 3 BD SAFETGLD INS 0.5 ML 8MMX30G 3
BD NEEDLE 18GX1 1/2" 3 BD SAFETYGLID INS 1 ML 6MMX31G 3
BD NEEDLE 19GX1 1/2" 3 BD SAFETYGLIDE 3 ML SYRINGE 3
BD NEEDLE 20GX1 1/2" 3 BD SAFETYGLIDE NEEDLE 3
BD NEEDLE 21GX1 1/2" 3 BD SAFETYGLIDE NEEDLE 18GX1.5" 3
BD NEEDLE 21GX1" 3 BD SAFETYGLIDE NEEDLE 21GX1" 3
BD NEEDLE 22GX1 1/2" 3 BD SAFETYGLIDE NEEDLE 21GX1.5" 3
BD NEEDLE 22GX1" 3 BD SAFETYGLIDE NEEDLE 22GX1.5" 3
BD NEEDLE 22GX3/4" 3 BD SAFETYGLIDE NEEDLE 25GX1" 3
BD NEEDLE 23GX1 1/2" 3 BD SAFETYGLIDE NEEDLE 27GX5/8" 3
BD NEEDLE 23GX1" 3 BD SAFETYGLIDE SYRINGE 27GX5/8 3
BD NEEDLE 24GX1" 3 BD SAFTYGLD INS 0.3 ML 6MMX31G 3
BD NEEDLE 25GX1" 3 BD SAFTYGLD INS 0.5 ML 6MMX31G 3
BD NEEDLE 25GX5/8" 3 BD SYR 0.3 ML 6MMX31G (1/2) 3
BD NEEDLE 26GX0.625" 3 BD SYR 0.3 ML 8MMX31G (1/2) 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
82019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
BD SYRINGE 0.3 ML 12.7MMX30G 3 BROMFENAC SODIUM 2
BD SYRINGE 0.5 ML 12.7MMX30G 3 BROMOCRIPTINE MESYLATE 2
BD SYRINGE-SAFETY GLIDE 3 BROMPHENIRAMINE-PSEUDOEPHED- 2
BD UF MICRO PEN NEEDLE 6MMX32G 3 DM
BD UF MINI PEN NEEDLE 5MMX31G 3 BUDESONIDE 0.25 MG/2 ML SUSP 4
BD UF NANO PEN NEEDLE 4MMX32G 3 BUDESONIDE 0.5 MG/2 ML SUSP 4
BD UF ORIG PEN NDL 12.7MMX29G 3 BUDESONIDE 1 MG/2 ML INH SUSP 4
BD UF SHORT PEN NEEDLE 8MMX31G 3 BUDESONIDE 32 MCG NASAL SPRAY 2
BD VEO INS 0.3ML 6MMX31G (1/2) 3 BUDESONIDE EC 3 MG CAPSULE 4
BD VEO INS SYRING 1 ML 6MMX31G 3 BUMETANIDE 0.5 MG TABLET 1
BD VEO INS SYRN 0.3 ML 6MMX31G 3 BUMETANIDE 1 MG TABLET 1
BD VEO INS SYRN 0.5 ML 6MMX31G 3 BUMETANIDE 2 MG TABLET 1
BEKYREE 1 BUPRENORPHINE PATCH 2 QL
BELLADONNA-OPIUM 2 BUPRENORPHINE 2 MG TABLET SL 2
BENAZEPRIL HCL 1 BUPRENORPHINE 8 MG TABLET SL 2
BENAZEPRIL-HYDROCHLOROTHIAZIDE 2 BUPRENORPHINE-NALOXONE 2
BENZEPRO 6% FOAMING CLOTHS 2 BUPROPION HCL 2 QL
BENZEPRO 7% CREAMY WASH 2 BUPROPION HCL SR 2 QL
BENZONATATE 2 BUPROPION XL 2 QL
BENZTROPINE MES 0.5 MG TAB 2 BUSPIRONE HCL 2
BENZTROPINE MES 1 MG TABLET 2 BUTALB-ACETAMINOPH-CAFF-CODEIN 2
BENZTROPINE MES 2 MG TABLET 2 BUTALB-CAFF-ACETAMINOPH-CODEIN 2
BETAMETHASONE DIPROP AUGMENTED 2 BUTALBITAL COMPOUND-CODEINE 2
BETAMETHASONE DIPROPIONATE 2 BUTALBITAL-ACETAMINOPHEN-CAFFE 2
BETAMETHASONE VALERATE 2 BUTALBITAL-ACETAMINOPHN 50-325 2
BETAXOLOL HCL 2 BUTALBITAL-ASPIRIN-CAFFEINE 2
BETHANECHOL CHLORIDE 2 BUTORPHANOL 10 MG/ML SPRAY 2 QL
BEXAROTENE 4 PA BYDUREON 3 QL
BEYAZ 3 BYDUREON BCISE 3 QL
BICALUTAMIDE 2 BYDUREON PEN 3 QL
BILTRICIDE 4 BYETTA 3 QL
BIMATOPROST 0.03% EYE DROPS 2 CABERGOLINE 2 QL
BISOPROLOL FUMARATE 2 CAFFEINE CIT 60 MG/3 ML ORAL 2
BISOPROLOL-HYDROCHLOROTHIAZIDE 1 CALCIPOTRIENE 2
BLISOVI 24 FE 1 CALCIPOTRIENE-BETAMETHASONE DP 2
BLISOVI FE 1 CALCITONIN-SALMON 2
BP WASH 7% LIQUID 2 CALCITRENE 2
BP WASH ACNE 4% TREATMENT PACK 2 CALCITRIOL 0.25 MCG CAPSULE 2
BPO 4% CREAMY WASH PACK 2 CALCITRIOL 0.5 MCG CAPSULE 2
BPO 4% GEL 2 CALCITRIOL 1 MCG/ML SOLUTION 2
BPO 6% FOAMING CLOTHS 2 CALCITRIOL 3 MCG/G OINTMENT 2 QL
BPO 8% GEL 2 CALCIUM ACETATE 667 MG CAPSULE 2
BREO ELLIPTA 3 CALCIUM ACETATE 667 MG GELCAP 2
BREVICON 4 CALCIUM ACETATE 667 MG TABLET 2
BRIELLYN 1 CAMILA 1
BRILINTA 4 CAMRESE 1
BRIMONIDINE TARTRATE 2 CAMRESE LO 1
BROMFED DM 2 CANDESARTAN CILEXETIL 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
92019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
CANDESARTAN-HYDROCHLOROTHIAZID 2 CETIRIZINE HCL 1 MG/ML SYRUP 2
CAPACET 2 CEVIMELINE HCL 2
CAPECITABINE 4 CHATEAL 1
CAPTOPRIL 1 CHERATUSSIN AC 2
CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 QL CHLORDIAZEPOXIDE HCL 2
CARBAGLU 4 PA CHLORDIAZEPOXIDE-AMITRIPTYLINE 2
CARBAMAZEPINE 100 MG TAB CHEW 1 CHLORDIAZEPOXIDE-CLIDINIUM 2
CARBAMAZEPINE 100 MG/5 ML SUSP 2 CHLORHEXIDINE 0.12% RINSE 2
CARBAMAZEPINE 200 MG TABLET 1 CHLOROQUINE PHOSPHATE 2
CARBAMAZEPINE ER 2 CHLOROTHIAZIDE 2
CARBIDOPA 2 CHLORPROMAZINE 10 MG TABLET 2
CARBIDOPA-LEVODOPA 2 CHLORPROMAZINE 100 MG TABLET 2
CARBIDOPA-LEVODOPA ER 2 CHLORPROMAZINE 200 MG TABLET 2
CARBIDOPA-LEVODOPA-ENTACAPONE 2 CHLORPROMAZINE 25 MG TABLET 2
CARBINOXAMINE 4 MG/5 ML LIQUID 2 CHLORPROMAZINE 50 MG TABLET 2
CARBINOXAMINE MALEATE 4 MG TAB 2 CHLORPROPAMIDE 1
CARETOUCH ALCOHOL PREP PAD 3 CHLORTHALIDONE 2
CARISOPRODOL 2 CHLORZOXAZONE 500 MG TABLET 2
CARISOPRODOL COMPOUND 2 CHOLESTYRAMINE 2
CARISOPRODOL COMPOUND-CODEINE 2 CHOLESTYRAMINE LIGHT 2
CARISOPRODOL-ASPIRIN 2 CHOLINE MAG TRISALICYLATE 2
CARISOPRODOL-ASPIRIN-CODEINE 2 CICLODAN 0.77% CREAM 2
CARTEOLOL HCL 2 CICLODAN 8% SOLUTION 2
CARTIA XT 2 CICLOPIROX 0.77% CREAM 2
CARVEDILOL 1 CICLOPIROX 0.77% GEL 2
CAZIANT 1 CICLOPIROX 0.77% TOPICAL SUSP 2
CEFACLOR 2 CICLOPIROX 1% SHAMPOO 2
CEFACLOR ER 2 CICLOPIROX 8% SOLUTION 2
CEFADROXIL 2 CILOSTAZOL 2
CEFDINIR 2 CIMETIDINE 200 MG TABLET 1
CEFDITOREN PIVOXIL 2 CIMETIDINE 300 MG TABLET 1
CEFIXIME 2 CIMETIDINE 300 MG/5 ML SOLN 2
CEFPODOXIME PROXETIL 2 CIMETIDINE 400 MG TABLET 1
CEFPROZIL 2 CIMETIDINE 800 MG TABLET 1
CEFTIBUTEN 2 CIPROFLOXACIN 0.2% OTIC SOLN 2
CEFUROXIME 2 CIPROFLOXACIN 0.3% EYE DROP 2
CELECOXIB 2 QL CIPROFLOXACIN 250 MG/5 ML SUSP 2
CENTERGY 2 CIPROFLOXACIN 500 MG/5 ML SUSP 2
CENTERGY DM 2 CIPROFLOXACIN ER 2
CEPHALEXIN 125 MG/5 ML SUSP 1 CIPROFLOXACIN HCL 100 MG TAB 1
CEPHALEXIN 250 MG CAPSULE 1 CIPROFLOXACIN HCL 250 MG TAB 1
CEPHALEXIN 250 MG TABLET 1 CIPROFLOXACIN HCL 500 MG TAB 1
CEPHALEXIN 250 MG/5 ML SUSP 1 CIPROFLOXACIN HCL 750 MG TAB 1
CEPHALEXIN 500 MG CAPSULE 1 CITALOPRAM HBR 10 MG TABLET 1 QL
CEPHALEXIN 500 MG TABLET 1 CITALOPRAM HBR 10 MG/5 ML SOLN 2 QL
CEPHALEXIN 750 MG CAPSULE 2 CITALOPRAM HBR 20 MG TABLET 1 QL
CESAMET 4 CITALOPRAM HBR 40 MG TABLET 1 QL
CETIRIZINE HCL 1 MG/ML SOLN 2 CLARAVIS 2 QL
Please visit Cigna.com/ifp-drug-list to see a complete listing.
102019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
CLARITHROMYCIN 2 CLOZAPINE ODT 25 MG TABLET 4
CLARITHROMYCIN ER 2 C-NATE DHA 1
CLEMASTINE FUMARATE 2 COARTEM 4 QL
CLINDACIN ETZ 1% PLEDGET 2 CODEINE SULFATE 2
CLINDACIN P 2 CODEINE-GUAIFEN 10-100 MG/5 ML 2
CLINDAMYCIN 2% VAGINAL CREAM 2 COLCHICINE 2
CLINDAMYCIN HCL 2 COLESTIPOL HCL 2
CLINDAMYCIN PALMITATE HCL 2 COLOCORT 2
CLINDAMYCIN PEDIATRIC 2 COLY-MYCIN S 4
CLINDAMYCIN PH 1% GEL 2 COMPLERA 3
CLINDAMYCIN PH 1% SOLUTION 2 COMPLETE NATAL DHA 1
CLINDAMYCIN PHOS 1% PLEDGET 2 COMPLETENATE 1
CLINDAMYCIN PHOS-BENZOYL PEROX 2 COMPRO 2
CLINDAMYCIN PHOSP 1% LOTION 2 CONSTULOSE 2
CLINDAMYCIN PHOSPHATE 1% FOAM 2 COREMINO 2
CLINDAMYCIN PHOS-TRETINOIN 2 CORMAX 2
CLINDAMYCIN-BENZOYL PEROXIDE 2 CORTISONE ACETATE 2
CLOBETASOL 0.05% CREAM 2 COVARYX 2
CLOBETASOL 0.05% GEL 2 COVARYX H.S. 2
CLOBETASOL 0.05% OINTMENT 2 CRIXIVAN 3
CLOBETASOL 0.05% SHAMPOO 2 CROMOLYN 100 MG/5 ML ORAL CONC 2
CLOBETASOL 0.05% SOLUTION 2 CROMOLYN 20 MG/2 ML NEB SOLN 2
CLOBETASOL 0.05% TOPICAL LOTN 2 CROMOLYN 4% EYE DROPS 2
CLOBETASOL EMOLLIENT 2 CRYSELLE 1
CLOBETASOL EMULSION 2 CUPRIMINE 4
CLOBETASOL PROP 0.05% FOAM 2 CURITY ALCOHOL PREPS 3
CLOBETASOL PROP 0.05% SPRAY 2 CYANOCOBALAMIN INJECTION 2
CLOCORTOLONE PIVALATE 2 CYCLAFEM 1
CLODAN 0.05% SHAMPOO 2 CYCLESSA 1
CLOMIPRAMINE HCL 4 CYCLOBENZAPRINE 10 MG TABLET 1
CLONAZEPAM 2 CYCLOBENZAPRINE 5 MG TABLET 1
CLONIDINE 2 CYCLOBENZAPRINE 7.5 MG TABLET 3
CLONIDINE HCL 0.1 MG TABLET 2 CYCLOPENTOLATE HCL 2
CLONIDINE HCL 0.2 MG TABLET 2 CYCLOPHOSPHAMIDE 25 MG CAPSULE 3
CLONIDINE HCL 0.3 MG TABLET 2 CYCLOPHOSPHAMIDE 50 MG CAPSULE 3
CLONIDINE HCL ER 2 CYCLOSERINE 2
CLOPIDOGREL 2 CYCLOSET 4
CLORAZEPATE DIPOTASSIUM 2 CYCLOSPORINE 100 MG CAPSULE 2
CLORPRES 2 CYCLOSPORINE 25 MG CAPSULE 2
CLOTRIMAZOLE 1% CREAM 2 CYCLOSPORINE MODIFIED 2
CLOTRIMAZOLE 1% SOLUTION 2 CYPROHEPTADINE 2 MG/5 ML SYRUP 2
CLOTRIMAZOLE 10 MG TROCHE 2 CYPROHEPTADINE 4 MG TABLET 2
CLOTRIMAZOLE-BETAMETHASONE 2 CYRED 1
CLOZAPINE 2 CYSTARAN 4 LDD
CLOZAPINE ODT 100 MG TABLET 4 CYTRA-2 2
CLOZAPINE ODT 12.5 MG TABLET 4 CYTRA-3 2
CLOZAPINE ODT 150 MG TABLET 4 CYTRA-K 2
CLOZAPINE ODT 200 MG TABLET 4 DANAZOL 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
112019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
DANTROLENE SODIUM 2 DIAZEPAM 10 MG RECTAL GEL SYST 2
DAPSONE 4 DIAZEPAM 10 MG TABLET 2
DARIFENACIN ER 2 DIAZEPAM 2 MG TABLET 2
DASETTA 1 DIAZEPAM 2.5 MG RECTAL GEL SYS 2
DAYSEE 1 DIAZEPAM 20 MG RECTAL GEL SYST 2
DEBLITANE 1 DIAZEPAM 5 MG TABLET 2
DECADRON 0.5 MG/5 ML ELIXIR 1 DIAZEPAM 5 MG/5 ML ORAL SOLN 2
DECARA 25,000 UNIT VEGICAP 4 QL DIAZEPAM 5 MG/5 ML SOLUTION 2
DECARA 50,000 UNIT SOFTGEL 4 QL DIAZEPAM 5 MG/ML ORAL CONC 2
DELYLA 1 DICLOFENAC 0.1% EYE DROPS 2
DEMECLOCYCLINE HCL 2 DICLOFENAC 1.5% TOPICAL SOLN 2
DEMSER 4 DICLOFENAC POTASSIUM 2
DENTA 5000 PLUS 2 DICLOFENAC SOD DR 25 MG TAB 2
DENTAGEL 2 DICLOFENAC SOD DR 50 MG TAB 2
DEPADE 2 DICLOFENAC SOD DR 75 MG TAB 2
DEPEN 4 DICLOFENAC SOD EC 25 MG TAB 2
DESCOVY 3 DICLOFENAC SOD EC 50 MG TAB 2
DESIPRAMINE HCL 2 DICLOFENAC SOD EC 75 MG TAB 2
DESLORATADINE 2 QL DICLOFENAC SODIUM 1% GEL 2 QL
DESMOPRESSIN 0.01% SOLUTION 2 DICLOFENAC SODIUM ER 2
DESMOPRESSIN 0.01% SPRAY 2 DICLOFENAC SODIUM-MISOPROSTOL 2
DESMOPRESSIN 0.1 MG/ML SOL 2 DICLOXACILLIN SODIUM 2
DESMOPRESSIN 10 MCG/0.1 ML SPR 2 DICYCLOMINE 10 MG CAPSULE 1
DESMOPRESSIN ACETATE 0.1 MG TB 2 DICYCLOMINE 10 MG/5 ML SOLN 2
DESMOPRESSIN ACETATE 0.2 MG TB 2 DICYCLOMINE 20 MG TABLET 1
DESOGEN 4 DIDANOSINE 2
DESOGESTREL-ETHINYL ESTRADIOL 1 DIFLORASONE DIACETATE 2
DESOGESTR-ETH ESTRAD ETH ESTRA 1 DIFLUNISAL 2
DESONIDE 2 DIGITEK 1
DESOXIMETASONE 2 DIGOX 1
DESVENLAFAXINE SUCCINATE ER 2 QL DIGOXIN 0.05 MG/ML SOLUTION 2
DEXAMETHASONE 1 DIGOXIN 0.125 MG TABLET 1
DEXAMETHASONE 0.1% EYE DROP 2 DIGOXIN 0.25 MG TABLET 1
DEXAMETHASONE INTENSOL 1 DIGOXIN 125 MCG TABLET 1
DEXILANT 3 ST, QL DIGOXIN 250 MCG TABLET 1
DEXMETHYLPHENIDATE ER 10 MG CP 2 DIHYDROERGOTAMINE MESYLATE 4 QL
DEXMETHYLPHENIDATE ER 15 MG CP 2 DILTIAZEM 120 MG TABLET 1
DEXMETHYLPHENIDATE ER 20 MG CP 2 DILTIAZEM 12HR ER 2
DEXMETHYLPHENIDATE ER 25 MG CP 2 DILTIAZEM 24HR CD 2
DEXMETHYLPHENIDATE ER 30 MG CP 2 DILTIAZEM 24HR ER 2
DEXMETHYLPHENIDATE ER 35 MG CP 2 DILTIAZEM 30 MG TABLET 1
DEXMETHYLPHENIDATE ER 40 MG CP 2 DILTIAZEM 60 MG TABLET 1
DEXMETHYLPHENIDATE ER 5 MG CAP 2 DILTIAZEM 90 MG TABLET 1
DEXMETHYLPHENIDATE HCL 2 DILTIAZEM ER 2
DEXTROAMPHETAMINE SULFATE 2 DILT-XR 2
DEXTROAMPHETAMINE SULFATE ER 2 DIPHENHYDRAMINE 12.5 MG/5 ML 2
DEXTROAMPHETAMINE-AMPHET ER 2 DIPHENHYDRAMINE 25 MG/10 ML 2
DEXTROAMPHETAMINE-AMPHETAMINE 2 DIPHENOXYLATE-ATROPINE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
122019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
DIPYRIDAMOLE 25 MG TABLET 2 EEMT 2
DIPYRIDAMOLE 50 MG TABLET 2 EEMT H.S. 2
DIPYRIDAMOLE 75 MG TABLET 2 EFAVIRENZ 2
DISKETS 2 PA ELINEST 1
DISOPYRAMIDE PHOSPHATE 2 ELIPHOS 2
DISULFIRAM 2 ELITE OB DHA 1
DIVALPROEX SODIUM 2 ELITE-OB 1
DIVALPROEX SODIUM ER 2 ELITE-OB 400 1
DOFETILIDE 4 QL ELLA 4
DONEPEZIL HCL 2 ELMIRON 4
DONEPEZIL HCL ODT 2 EMOQUETTE 1
DORZOLAMIDE HCL 2 EMSAM 4 QL
DORZOLAMIDE-TIMOLOL 2 EMTRIVA 3
DOTHELLE DHA 1 EMVERM 2
DOXAZOSIN MESYLATE 1 ENALAPRIL MALEATE 1
DOXEPIN 10 MG CAPSULE 2 ENALAPRIL-HYDROCHLOROTHIAZIDE 2
DOXEPIN 10 MG/ML ORAL CONC 2 ENDOCET 2
DOXEPIN 100 MG CAPSULE 2 ENOXAPARIN SODIUM 4 QL
DOXEPIN 150 MG CAPSULE 2 ENPRESSE 1
DOXEPIN 25 MG CAPSULE 2 ENSKYCE 1
DOXEPIN 5% CREAM 4 ENTACAPONE 2
DOXEPIN 50 MG CAPSULE 2 ENTECAVIR 0.5 MG TABLET 4
DOXEPIN 75 MG CAPSULE 2 ENTECAVIR 1 MG TABLET 4
DOXERCALCIFEROL 0.5 MCG CAP 2 ENTRESTO 3 PA
DOXERCALCIFEROL 1 MCG CAPSULE 2 ENULOSE 2
DOXERCALCIFEROL 2.5 MCG CAP 2 EPINASTINE HCL 2
DOXYCYCLINE HYC DR 100 MG TAB 2 EPINEPHRINE 0.15 MG AUTO-INJCT 2 QL
DOXYCYCLINE HYC DR 150 MG TAB 2 EPINEPHRINE 0.3 MG AUTO-INJECT 2 QL
DOXYCYCLINE HYC DR 200 MG TAB 2 EPITOL 1
DOXYCYCLINE HYC DR 50 MG TAB 2 EPLERENONE 2
DOXYCYCLINE HYC DR 75 MG TAB 2 EPROSARTAN MESYLATE 2
DOXYCYCLINE HYCLATE 100 MG CAP 2 ERGOLOID MESYLATES 1
DOXYCYCLINE HYCLATE 100 MG TAB 2 ERGOMAR 4
DOXYCYCLINE HYCLATE 20 MG TAB 2 ERRIN 1
DOXYCYCLINE HYCLATE 50 MG CAP 2 ERY 2
DOXYCYCLINE MONOHYDRATE 2 ERYTHROCIN STEARATE 2
DRONABINOL 4 ERYTHROMYCIN 2
DROSPIRENONE-EE 3-0.02 MG TAB 1 ERYTHROMYCIN ETHYLSUCCINATE 2
DROSPIRENONE-EE 3-0.03 MG TAB 1 ERYTHROMYCIN-BENZOYL PEROXIDE 2
DROSPIRENONE-ETH ESTRA-LEVOMEF 1 ESCITALOPRAM OXALATE 2 QL
DULOXETINE HCL 2 QL ESOMEPRAZOLE MAG DR 20 MG CAP 2 QL
DUTASTERIDE 2 ESOMEPRAZOLE MAG DR 40 MG CAP 2 QL
DUTASTERIDE-TAMSULOSIN 2 ESOMEPRAZOLE STRONTIUM 2 QL
EASY TOUCH ALCOHOL PREP PADS 3 ESTARYLLA 1
ECONAZOLE NITRATE 2 ESTAZOLAM 2
ECONTRA EZ 4 ESTRADIOL 0.025 MG PATCH 2
ED-SPAZ 1 ESTRADIOL 0.0375 MG PATCH 2
EDURANT 3 ESTRADIOL 0.0375 MG/DAY PATCH 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
132019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
ESTRADIOL 0.05 MG PATCH 2 FEMCON FE 4
ESTRADIOL 0.06 MG/DAY PATCH 2 FEMYNOR 1
ESTRADIOL 0.075 MG PATCH 2 FENOFIBRATE 2
ESTRADIOL 0.075 MG/DAY PATCH 2 FENOFIBRIC ACID 2
ESTRADIOL 0.1 MG PATCH 2 FENOPROFEN 600 MG TABLET 2
ESTRADIOL 0.5 MG TABLET 1 FENTANYL PATCH 2 PA, QL
ESTRADIOL 1 MG TABLET 1 FENTANYL CIT OTFC 1,200 MCG 4 PA
ESTRADIOL 10 MCG VAGINAL INSRT 2 FENTANYL CIT OTFC 1,600 MCG 4 PA
ESTRADIOL 2 MG TABLET 1 FENTANYL CITRATE OTFC 200 MCG 4 PA
ESTRADIOL TDS 0.025 MG/DAY 2 FENTANYL CITRATE OTFC 400 MCG 4 PA
ESTRADIOL TDS 0.0375 MG/DAY 2 FENTANYL CITRATE OTFC 600 MCG 4 PA
ESTRADIOL TDS 0.05 MG/DAY 2 FENTANYL CITRATE OTFC 800 MCG 4 PA
ESTRADIOL TDS 0.06 MG/DAY 2 FEXOFENADINE HCL 180 MG TABLET 2
ESTRADIOL TDS 0.075 MG/DAY 2 FEXOFENADINE HCL 30 MG TABLET 2
ESTRADIOL TDS 0.1 MG/DAY 2 FEXOFENADINE HCL 60 MG TABLET 2
ESTRADIOL-NORETHINDRONE ACETAT 2 FINASTERIDE 5 MG TABLET 2
ESTROGEN-METHYLTESTOSTERONE 2 FIORICET 2
ESTROPIPATE 2 FLAVOXATE HCL 2
ESTROSTEP FE 4 FLECAINIDE ACETATE 2
ESZOPICLONE 2 FLOVENT DISKUS 3
ETHACRYNIC ACID 2 FLOVENT HFA 3
ETHAMBUTOL HCL 2 FLUCONAZOLE 10 MG/ML SUSP 2
ETHOSUXIMIDE 2 FLUCONAZOLE 100 MG TABLET 2
ETHYL CHLORIDE 2 FLUCONAZOLE 150 MG TABLET 1
ETHYNODIOL-ETHINYL ESTRADIOL 1 FLUCONAZOLE 200 MG TABLET 2
ETIDRONATE DISODIUM 2 FLUCONAZOLE 40 MG/ML SUSP 2
ETODOLAC 2 FLUCONAZOLE 50 MG TABLET 2
ETODOLAC ER 2 FLUCYTOSINE 4
ETOPOSIDE 4 FLUDROCORTISONE ACETATE 2
EVOTAZ 3 FLUNISOLIDE 2
EXEMESTANE 2 FLUOCINOLONE ACETONIDE 2
EXTRA-VIRT PLUS DHA 1 FLUOCINOLONE ACETONIDE OIL 2
EZETIMIBE 2 FLUOCINONIDE 0.05% CREAM 2
EZETIMIBE-SIMVASTATIN 2 FLUOCINONIDE 0.05% GEL 2
FALLBACK SOLO 4 FLUOCINONIDE 0.05% OINTMENT 2
FALMINA 1 FLUOCINONIDE 0.05% SOLUTION 2
FAMCICLOVIR 2 FLUOCINONIDE 0.1% CREAM 2
FAMOTIDINE 20 MG TABLET 1 FLUOCINONIDE-E 2
FAMOTIDINE 40 MG TABLET 1 FLUORABON 2
FAMOTIDINE 40 MG/5 ML SUSP 2 FLUORIDE 2
FARESTON 4 FLUORIDEX 2
FARXIGA 3 QL FLUORIDEX DAILY DEFENSE 2
FAYOSIM 1 FLUORITAB 2
FELBAMATE 400 MG TABLET 4 FLUOROMETHOLONE 2
FELBAMATE 600 MG TABLET 4 FLUOROURACIL 0.5% CREAM 2
FELBAMATE 600 MG/5 ML SUSP 4 FLUOROURACIL 2% TOPICAL SOLN 2
FELODIPINE ER 2 FLUOROURACIL 5% CREAM 2
FEM PH 2 FLUOROURACIL 5% TOPICAL SOLN 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
142019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
FLUOXETINE 20 MG/5 ML SOLUTION 2 QL GALANTAMINE ER 2 QL
FLUOXETINE DR 2 QL GALANTAMINE HBR 2
FLUOXETINE HCL 10 MG CAPSULE 1 QL GALANTAMINE HYDROBROMIDE 2
FLUOXETINE HCL 10 MG TABLET 1 QL GATIFLOXACIN 2
FLUOXETINE HCL 20 MG CAPSULE 1 QL GAVILYTE-C 2
FLUOXETINE HCL 20 MG TABLET 1 QL GAVILYTE-G 2
FLUOXETINE HCL 40 MG CAPSULE 1 QL GAVILYTE-H AND BISACODYL 2
FLUOXETINE HCL 60 MG TABLET 1 QL GAVILYTE-N 2
FLUPHENAZINE 1 MG TABLET 2 GEMFIBROZIL 2
FLUPHENAZINE 10 MG TABLET 2 GENERESS FE 4
FLUPHENAZINE 2.5 MG TABLET 2 GENERLAC 2
FLUPHENAZINE 2.5 MG/5 ML ELIX 2 GENGRAF 2
FLUPHENAZINE 5 MG TABLET 2 GENTAK 2
FLUPHENAZINE 5 MG/ML CONC 2 GENTAMICIN 0.1% CREAM 2
FLURA-DROPS 2 GENTAMICIN 0.1% OINTMENT 2
FLURANDRENOLIDE 2 GENTAMICIN 0.3% EYE DROPS 2
FLURAZEPAM HCL 2 GENTAMICIN 0.3% EYE OINTMENT 2
FLURBIPROFEN 2 GENTAMICIN 3 MG/ML EYE DROPS 2
FLURBIPROFEN SODIUM 2 GENVOYA 3
FLUTAMIDE 2 GIANVI 1
FLUTICASONE PROP 0.005% OINT 2 GILDAGIA 1
FLUTICASONE PROP 0.05% CREAM 2 GILDESS 1
FLUTICASONE PROP 0.05% LOTION 2 GILDESS 24 FE 1
FLUTICASONE PROP 50 MCG SPRAY 2 GILDESS FE 1
FLUTICASONE-SALMETEROL 2 GLEOSTINE 4
FLUVASTATIN ER 2 GLIMEPIRIDE 1
FLUVASTATIN SODIUM 2 GLIPIZIDE 1
FLUVOXAMINE MALEATE 2 QL GLIPIZIDE ER 1
FLUVOXAMINE MALEATE ER 2 QL GLIPIZIDE XL 1
FOCALGIN 90 DHA 1 GLIPIZIDE-METFORMIN 2
FOCALGIN CA 1 GLUCAGEN 1 MG HYPOKIT 3
FOLIC ACID 1 MG TABLET 2 GLUCAGON EMERGENCY KIT 3
FOLIVANE-OB 1 GLYBURIDE 1
FONDAPARINUX SODIUM 4 QL GLYBURIDE MICRONIZED 1
FORMADON 2 GLYBURIDE-METFORMIN HCL 2
FORMALDEHYDE 2 GLYCINE 1.5% IRRIGATION 2
FORTICAL 2 GLYCOPYRROLATE 1 MG TABLET 2
FOSAMPRENAVIR CALCIUM 2 GLYCOPYRROLATE 2 MG TABLET 2
FOSINOPRIL SODIUM 1 GLYDO 2
FOSINOPRIL-HYDROCHLOROTHIAZIDE 2 GRANISETRON HCL 0.1 MG/ML VIAL 2
FROVATRIPTAN SUCCINATE 2 QL GRANISETRON HCL 1 MG TABLET 2
FUROSEMIDE 10 MG/ML SOLUTION 1 GRANISETRON HCL 1 MG/ML VIAL 2
FUROSEMIDE 20 MG TABLET 1 GRANISETRON HCL 4 MG/4 ML VIAL 2
FUROSEMIDE 40 MG TABLET 1 GRISEOFULVIN 2
FUROSEMIDE 40 MG/5 ML SOLN 1 GRISEOFULVIN ULTRAMICROSIZE 2
FUROSEMIDE 80 MG TABLET 1 GUAIATUSSIN AC 2
FYAVOLV 2 GUAIFEN-CODEINE 100-10 MG/5 ML 2
GABAPENTIN 2 GUAIFENESIN AC 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
152019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
GUAIFENESIN-CODEINE SYRUP 2 HYDROCODONE-ACETAMIN 5-325 MG 2
GUANFACINE HCL 1 HYDROCODONE-ACETAMIN 7.5-300 2
GUANFACINE HCL ER 2 HYDROCODONE-ACETAMIN 7.5-325 2
GUANIDINE HCL 2 HYDROCODONE-ACETAMN 7.5-325/15 2
GYNAZOLE 1 2 HYDROCODONE-CHLORPHENIRAMNE ER 2
HALOBETASOL PROPIONATE 2 HYDROCODONE-HOMATROPINE MBR 2
HALOPERIDOL 0.5 MG TABLET 2 HYDROCODONE-IBUPROFEN 2
HALOPERIDOL 1 MG TABLET 2 HYDROCORTISONE 1% ABSORBASE 2
HALOPERIDOL 10 MG TABLET 2 HYDROCORTISONE 1% CREAM 2
HALOPERIDOL 2 MG TABLET 2 HYDROCORTISONE 1% OINTMENT 2
HALOPERIDOL 20 MG TABLET 2 HYDROCORTISONE 10 MG TABLET 2
HALOPERIDOL 5 MG TABLET 2 HYDROCORTISONE 100 MG/60 ML 2
HALOPERIDOL LAC 2 MG/ML CONC 2 HYDROCORTISONE 2.5% CREAM 2
HEATHER 1 HYDROCORTISONE 2.5% LOTION 2
HEMENATAL OB 1 HYDROCORTISONE 2.5% OINTMENT 2
HEMENATAL OB + DHA 1 HYDROCORTISONE 20 MG TABLET 2
HEMMOREX-HC 2 HYDROCORTISONE 5 MG TABLET 2
HEPARIN SOD 5,000 UNIT/ 0.5 ML 2 HYDROCORTISONE AC 25 MG SUPP 2
HEPARIN SOD 5,000 UNIT/0.5 ML 2 HYDROCORTISONE AC 30 MG SUPP 2
HOMATROPAIRE 2 HYDROCORTISONE BUTYRATE 2
HOMATROPINE HYDROBROMIDE 2 HYDROCORTISONE VALERATE 2
HUMALOG 3 HYDROCORTISONE-ACETIC ACID 2
HUMALOG JUNIOR KWIKPEN 3 HYDROCORTISONE-PRAMOXINE 2
HUMALOG KWIKPEN U-100 3 HYDROMET 2
HUMALOG KWIKPEN U-200 3 HYDROMORPHONE 1 MG/ML SOLUTION 2
HUMALOG MIX 50-50 3 HYDROMORPHONE 2 MG TABLET 2
HUMALOG MIX 50-50 KWIKPEN 3 HYDROMORPHONE 3 MG SUPPOS 2
HUMALOG MIX 75-25 3 HYDROMORPHONE 4 MG TABLET 2
HUMALOG MIX 75-25 KWIKPEN 3 HYDROMORPHONE 5 MG/5 ML SOLN 2
HUMULIN 70/30 KWIKPEN 3 HYDROMORPHONE 8 MG TABLET 2
HUMULIN 70-30 3 HYDROMORPHONE ER 2 QL
HUMULIN N 3 HYDROXYCHLOROQUINE SULFATE 2
HUMULIN N KWIKPEN 3 HYDROXYUREA 2
HUMULIN R 3 HYDROXYZINE 10 MG/5 ML SOLN 2
HUMULIN R U-500 3 HYDROXYZINE 10 MG/5 ML SYRUP 2
HUMULIN R U-500 KWIKPEN 3 HYDROXYZINE HCL 10 MG TABLET 2
HYDRALAZINE 10 MG TABLET 2 HYDROXYZINE HCL 25 MG TABLET 2
HYDRALAZINE 100 MG TABLET 2 HYDROXYZINE HCL 50 MG TABLET 2
HYDRALAZINE 25 MG TABLET 2 HYDROXYZINE PAMOATE 2
HYDRALAZINE 50 MG TABLET 2 HYOPHEN 2
HYDROCHLOROTHIAZIDE 1 HYOSCYAMINE 0.125 MG ODT 1
HYDROCOD-CPM-PSEUDOEPHEDRINE 2 HYOSCYAMINE 0.125 MG TAB SL 1
HYDROCODONE-ACETAMIN 10-300 MG 2 HYOSCYAMINE 0.125 MG/5 ML ELIX 2
HYDROCODONE-ACETAMIN 10-325 MG 2 HYOSCYAMINE 0.125 MG/ML DROP 2
HYDROCODONE-ACETAMIN 2.5-108/5 2 HYOSCYAMINE SULF 0.125 MG TAB 1
HYDROCODONE-ACETAMIN 2.5-325 2 HYOSCYAMINE SULFATE ER 1
HYDROCODONE-ACETAMIN 5-217/10 2 HYOSCYAMINE SULFATE SR 1
HYDROCODONE-ACETAMIN 5-300 MG 2 HYOSYNE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
162019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
IBANDRONATE SODIUM 150 MG TAB 2 JEVANTIQUE LO 2
IBU 1 JINTELI 2
IBUDONE 2 JOLESSA 1
IBUPROFEN 100 MG/5 ML SUSP 1 JOLIVETTE 1
IBUPROFEN 400 MG TABLET 1 JULEBER 1
IBUPROFEN 600 MG TABLET 1 JULUCA 4
IBUPROFEN 800 MG TABLET 1 JUNEL 1
IMATINIB MESYLATE 4 PA JUNEL FE 1
IMIPRAMINE HCL 2 JUNEL FE 24 1
IMIPRAMINE PAMOATE 2 KAITLIB FE 1
IMIQUIMOD 2 KALETRA 100-25 MG TABLET 3
INCONTROL ALCOHOL PADS 3 KALETRA 200-50 MG TABLET 3
INCRUSE ELLIPTA 3 KARIVA 1
INDAPAMIDE 1 KELNOR 1-35 1
INDOMETHACIN 25 MG CAPSULE 2 KELNOR 1-50 1
INDOMETHACIN 50 MG CAPSULE 2 KETOCONAZOLE 2
INDOMETHACIN ER 2 KETOPROFEN 2
INTELENCE 200 MG TABLET 3 KETOROLAC 0.4% OPHTH SOLUTION 2
INTELENCE 25 MG TABLET 3 KETOROLAC 0.5% OPHTH SOLUTION 2
INTROVALE 1 KETOROLAC 10 MG TABLET 2 QL
IODOSORB 2 KETOROLAC 15 MG/ML CARPUJECT 2 QL
IOPHEN-C NR 2 KETOROLAC 15 MG/ML ISECURE SYR 2 QL
IPRATROPIUM 0.03% SPRAY 2 KETOROLAC 15 MG/ML SYRINGE 2 QL
IPRATROPIUM 0.06% SPRAY 2 KETOROLAC 15 MG/ML VIAL 2 QL
IPRATROPIUM BR 0.02% SOLN 1 KETOROLAC 30 MG/ML CARPUJECT 2 QL
IPRATROPIUM-ALBUTEROL 2 KETOROLAC 30 MG/ML ISECURE SYR 2 QL
IRBESARTAN 2 KETOROLAC 30 MG/ML SYRINGE 2 QL
IRBESARTAN-HYDROCHLOROTHIAZIDE 2 KETOROLAC 30 MG/ML VIAL 2 QL
ISENTRESS 3 KETOROLAC 300 MG/10 ML VIAL 2 QL
ISENTRESS HD 3 KETOROLAC 60 MG/2 ML CARPUJECT 2 QL
ISIBLOOM 1 KETOROLAC 60 MG/2 ML SYRINGE 2 QL
ISOCHRON 2 KETOROLAC 60 MG/2 ML VIAL 2 QL
ISONIAZID 100 MG TABLET 1 KIMIDESS 1
ISONIAZID 300 MG TABLET 1 KIONEX 2
ISONIAZID 50 MG/5 ML SOLUTION 2 KLOR-CON 10 2
ISOSORBIDE DINITRATE 2 KLOR-CON 20 MEQ PACKET 2
ISOSORBIDE DINITRATE ER 2 KLOR-CON 8 2
ISOSORBIDE MONONITRATE 1 KLOR-CON M10 2
ISOSORBIDE MONONITRATE ER 1 KLOR-CON M20 2
ISOTRETINOIN 2 QL KLOR-CON SPRINKLE 2
ISOXSUPRINE HCL 2 KOMBIGLYZE XR 3 QL
ISRADIPINE 2 K-SOL 2
ITRACONAZOLE 3 K-TAB ER 8 MEQ TABLET 2
IV ANTISEPTIC WIPES 3 KURVELO 1
IV PREP WIPES 3 LABETALOL HCL 100 MG TABLET 2
IVERMECTIN 2 LABETALOL HCL 200 MG TABLET 2
JANTOVEN 1 LABETALOL HCL 300 MG TABLET 2
JENCYCLA 1 LACTATED RINGERS IRRIGATION 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
172019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
LACTULOSE 2 LEVOCARNITINE 330 MG TABLET 2
LAMIVUDINE 2 LEVOCETIRIZINE 2.5 MG/5 ML SOL 2
LAMIVUDINE HBV 2 LEVOCETIRIZINE 5 MG TABLET 2
LAMIVUDINE-ZIDOVUDINE 2 LEVOFLOXACIN 0.5% EYE DROPS 2
LAMOTRIGINE 2 LEVOFLOXACIN 25 MG/ML SOLUTION 2
LAMOTRIGINE (BLUE) 2 LEVOFLOXACIN 250 MG TABLET 2
LAMOTRIGINE (GREEN) 2 LEVOFLOXACIN 250 MG/10 ML SOLN 2
LAMOTRIGINE (ORANGE) 2 LEVOFLOXACIN 500 MG TABLET 2
LAMOTRIGINE ER 2 LEVOFLOXACIN 500 MG/20 ML SOLN 2
LAMOTRIGINE ODT 2 LEVOFLOXACIN 750 MG TABLET 2
LAMOTRIGINE ODT (BLUE) 2 LEVOMEFOLATE DHA 1
LAMOTRIGINE ODT (GREEN) 2 LEVOMEFOLATE-ALGAL 15 MG CAP 2
LAMOTRIGINE ODT (ORANGE) 2 LEVOMEFOLATE-ALGAL 7.5 MG CAP 2
LANSOPRAZOL-AMOXICIL-CLARITHRO 2 LEVONEST 1
LANSOPRAZOLE DR 15 MG CAPSULE 2 QL LEVONORGESTREL-ETH ESTRADIOL 1
LANSOPRAZOLE DR 30 MG CAPSULE 2 QL LEVONORG-ETH ESTRAD ETH ESTRAD 1
LARIN 1 LEVORA-28 1
LARIN 24 FE 1 LEVORPHANOL TARTRATE 2
LARIN FE 1 LEVOTHYROXINE 100 MCG TABLET 1
LARISSIA 1 LEVOTHYROXINE 112 MCG TABLET 1
LATANOPROST 0.005% EYE DROPS 2 LEVOTHYROXINE 125 MCG TABLET 1
LATUDA 4 ST, QL LEVOTHYROXINE 137 MCG TABLET 1
LAYOLIS FE 4 LEVOTHYROXINE 150 MCG TABLET 1
LEENA 1 LEVOTHYROXINE 175 MCG TABLET 1
LEFLUNOMIDE 2 LEVOTHYROXINE 200 MCG TABLET 1
LESSINA 1 LEVOTHYROXINE 25 MCG TABLET 1
LETROZOLE 2 LEVOTHYROXINE 300 MCG TABLET 1
LEUCOVORIN CALCIUM 10 MG TAB 2 LEVOTHYROXINE 50 MCG TABLET 1
LEUCOVORIN CALCIUM 15 MG TAB 2 LEVOTHYROXINE 75 MCG TABLET 1
LEUCOVORIN CALCIUM 25 MG TAB 2 LEVOTHYROXINE 88 MCG TABLET 1
LEUCOVORIN CALCIUM 5 MG TAB 2 LEVOXYL 1
LEUKERAN 4 LEXIVA 50 MG/ML SUSPENSION 3
LEUPROLIDE 2WK 1 MG/0.2 ML KIT 2 PA LIDOCAINE 5% OINTMENT 2 QL
LEUPROLIDE 2WK 14 MG/2.8 ML KT 2 PA LIDOCAINE 5% PATCH 2
LEVALBUTEROL CONCENTRATE 2 LIDOCAINE HCL 2% JELLY 2
LEVALBUTEROL HCL 2 LIDOCAINE HCL 4% SOLUTION 2
LEVALBUTEROL TARTRATE HFA 2 LIDOCAINE HCL VISCOUS 1
LEVETIRACETAM 1,000 MG TABLET 2 LIDOCAINE-HC 2.8-0.55% GEL 2
LEVETIRACETAM 100 MG/ML SOLN 2 LIDOCAINE-HC 3-0.5% CREAM 2
LEVETIRACETAM 250 MG TABLET 2 LIDOCAINE-HC 3-0.5% CREAM KIT 2
LEVETIRACETAM 500 MG TABLET 2 LIDOCAINE-HYDROCORT 3-2.5% GEL 2
LEVETIRACETAM 500 MG/5 ML SOLN 2 LIDOCAINE-PRILOCAINE 2
LEVETIRACETAM 750 MG TABLET 2 LILLOW 1
LEVETIRACETAM ER 2 LINDANE 2
LEVLEN 28 1 LINEZOLID 100 MG/5 ML SUSP 4 PA
LEVOBUNOLOL HCL 2 LINEZOLID 600 MG TABLET 2 PA
LEVOCARNITINE 1 G/10 ML SOLN 2 LIOTHYRONINE SOD 25 MCG TAB 2
LEVOCARNITINE 200 MG/ML VIAL 2 LIOTHYRONINE SOD 5 MCG TAB 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
182019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
LIOTHYRONINE SOD 50 MCG TAB 2 MATERNITY 1
LISINOPRIL 1 MATZIM LA 2
LISINOPRIL-HYDROCHLOROTHIAZIDE 1 MECLIZINE 12.5 MG TABLET 2
LITHIUM 2 MECLIZINE 25 MG TABLET 2
LITHIUM CARBONATE 150 MG CAP 1 MECLOFENAMATE SODIUM 2
LITHIUM CARBONATE 300 MG CAP 1 MEDROL 4
LITHIUM CARBONATE 300 MG TAB 1 MEDROXYPROGESTERONE ACETATE 1
LITHIUM CARBONATE 600 MG CAP 1 MEFENAMIC ACID 2
LITHIUM CARBONATE ER 2 MEFLOQUINE HCL 2 QL
LITHIUM ER 450 MG TABLET 2 MEGESTROL ACETATE 2
L-METHYLFOLATE 2 MELODETTA 24 FE 1
L-METHYLFOLATE CALCIUM 2 MELOXICAM 15 MG TABLET 1
L-METHYLFOLATE FORTE 2 MELOXICAM 7.5 MG TABLET 1
LO LOESTRIN FE 3 MELOXICAM 7.5 MG/5 ML SUSP 2
LOESTRIN 4 MELPHALAN 2
LOESTRIN FE 4 MEMANTINE HCL 2
LOMEDIA 24 FE 1 MENEST 4
LOPERAMIDE 2 MG CAPSULE 2 MEPERIDINE 100 MG TABLET 2
LOPINAVIR-RITONAVIR 2 MEPERIDINE 50 MG TABLET 2
LOPREEZA 2 MEPERIDINE 50 MG/5 ML SOLUTION 2
LORAZEPAM 0.5 MG TABLET 2 MEPHYTON 4
LORAZEPAM 1 MG TABLET 2 MEPROBAMATE 2
LORAZEPAM 2 MG TABLET 2 MERCAPTOPURINE 2
LORAZEPAM 2 MG/ML ORAL CONCENT 2 MESALAMINE 4
LORAZEPAM INTENSOL 2 METADATE ER 2
LORCET 2 METAPROTERENOL SULFATE 2
LORCET HD 2 METAXALL 2
LORCET PLUS 2 METAXALONE 2
LORTAB 10 MG-300 MG/15 ML ELXR 2 METFORMIN HCL 1
LORYNA 1 METFORMIN HCL ER 500 MG TABLET 2
LOSARTAN POTASSIUM 1 METFORMIN HCL ER 750 MG TABLET 2
LOSARTAN-HYDROCHLOROTHIAZIDE 1 METHADONE 10 MG/5 ML SOLUTION 2 PA
LOSEASONIQUE 4 METHADONE 10 MG/ML ORAL CONC 2 PA
LOVASTATIN 1 METHADONE 40 MG TABLET DISPR 2 PA
LOW-OGESTREL 1 METHADONE 5 MG/5 ML SOLUTION 2 PA
LOXAPINE 2 METHADONE HCL 10 MG TABLET 2 PA
LUDENT FLUORIDE 2 METHADONE HCL 5 MG TABLET 2 PA
LUGOL'S SOLUTION 2 METHADONE INTENSOL 2 PA
LUTERA 1 METHADOSE 40 MG TABLET DISPR 2 PA
LYRICA 4 QL METHAMPHETAMINE HCL 2
LYSODREN 4 METHAZOLAMIDE 2
LYZA 1 METHENAMINE HIPPURATE 2
MACNATAL CN DHA 1 METHENAMINE MANDELATE 2
MALATHION 2 METHERGINE 2
MAPROTILINE HCL 2 METHIMAZOLE 2
MARGESIC 2 METHITEST 2
MARLISSA 1 METHOCARBAMOL 500 MG TABLET 2
MARTEN-TAB 2 METHOCARBAMOL 750 MG TABLET 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
192019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
METHOTREXATE 2.5 MG TABLET 2 MICONAZOLE 3 200 MG VAG SUPP 1
METHOXSALEN 4 MICORT-HC 2
METHSCOPOLAMINE BROMIDE 2 MICROGESTIN 1
METHYCLOTHIAZIDE 2 MICROGESTIN 24 FE 3
METHYLDOPA 1 MICROGESTIN FE 1.5-30 TAB 1
METHYLDOPA-HYDROCHLOROTHIAZIDE 2 MICROGESTIN FE 1-20 TABLET 4
METHYLERGONOVINE 0.2 MG TABLET 2 MIDAZOLAM HCL 2 MG/ML SYRUP 2
METHYLPHENIDATE ER 10 MG CAP 2 MIDODRINE HCL 2
METHYLPHENIDATE ER 10 MG TAB 2 MIGERGOT 2
METHYLPHENIDATE ER 18 MG TAB 2 MIGLITOL 2
METHYLPHENIDATE ER 20 MG CAP 2 MILI 1
METHYLPHENIDATE ER 20 MG TAB 2 MIMVEY 2
METHYLPHENIDATE ER 27 MG TAB 2 MIMVEY LO 2
METHYLPHENIDATE ER 30 MG CAP 2 MINASTRIN 24 FE 3
METHYLPHENIDATE ER 36 MG TAB 2 MINITRAN 2
METHYLPHENIDATE ER 40 MG CAP 2 MINOCYCLINE ER 135 MG TABLET 2
METHYLPHENIDATE ER 54 MG TAB 2 MINOCYCLINE ER 45 MG TABLET 2
METHYLPHENIDATE HCL 2 MINOCYCLINE ER 90 MG TABLET 2
METHYLPHENIDATE HCL CD 2 MINOCYCLINE HCL 2
METHYLPHENIDATE HCL ER 2 MINOXIDIL 10 MG TABLET 2
METHYLPHENIDATE LA 2 MINOXIDIL 2.5 MG TABLET 2
METHYLPREDNISOLONE 2 MIRCETTE 4
METHYLTESTOSTERONE 2 MIRTAZAPINE 2
METIPRANOLOL 2 MISOPROSTOL 2
METOCLOPRAMIDE 10 MG TABLET 1 MODAFINIL 4 PA
METOCLOPRAMIDE 10 MG/10 ML SOL 1 MODERIBA 2
METOCLOPRAMIDE 5 MG TABLET 1 MODICON 4
METOCLOPRAMIDE 5 MG/5 ML SOLN 1 MOEXIPRIL HCL 2
METOCLOPRAMIDE HCL ODT 2 MOEXIPRIL-HYDROCHLOROTHIAZIDE 2
METOLAZONE 2 MOLINDONE HCL 2
METOPROLOL SUCCINATE 2 MOMETASONE FUROATE 2
METOPROLOL TARTRATE 100 MG TAB 1 MONDOXYNE NL 2
METOPROLOL TARTRATE 25 MG TAB 1 MONO-LINYAH 1
METOPROLOL TARTRATE 37.5 MG TB 2 MONONESSA 1
METOPROLOL TARTRATE 50 MG TAB 1 MONTELUKAST SODIUM 2
METOPROLOL TARTRATE 75 MG TAB 2 MORGIDOX 100 MG CAPSULE 2
METOPROLOL-HYDROCHLOROTHIAZIDE 2 MORGIDOX 50 MG CAPSULE 2
METRONIDAZOLE 0.75% CREAM 2 MORPHINE SULF 10 MG SUPPOS 2
METRONIDAZOLE 0.75% LOTION 2 MORPHINE SULF 10 MG/5 ML SOLN 2
METRONIDAZOLE 250 MG TABLET 2 MORPHINE SULF 100 MG/5 ML SOLN 2
METRONIDAZOLE 375 MG CAPSULE 2 MORPHINE SULF 20 MG SUPPOS 2
METRONIDAZOLE 500 MG TABLET 2 MORPHINE SULF 20 MG/5 ML SOLN 2
METRONIDAZOLE TOP 1% GEL PUMP 2 MORPHINE SULF 30 MG SUPPOS 2
METRONIDAZOLE TOPICAL 0.75% GL 2 MORPHINE SULF 5 MG SUPPOS 2
METRONIDAZOLE TOPICAL 1% GEL 2 MORPHINE SULFATE ER 2 QL
METRONIDAZOLE VAGINAL 0.75% GL 2 MORPHINE SULFATE IR 15 MG TAB 2
MEXILETINE HCL 2 MORPHINE SULFATE IR 30 MG TAB 2
MIBELAS 24 FE 1 MOXEZA 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
202019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
MOXIFLOXACIN 0.5% EYE DROPS 2 NAPROXEN DR 375 MG TABLET 1
MOXIFLOXACIN HCL 400 MG TABLET 2 NAPROXEN DR 500 MG TABLET 1
MULTAQ 4 NAPROXEN SOD ER 375 MG TABLET 2
MULTIVITAMIN AND FLUORIDE 2 NAPROXEN SODIUM 275 MG TAB 1
MULTI-VITAMIN W-FLUORIDE 2 NAPROXEN SODIUM 550 MG TAB 1
MULTI-VITAMIN WITH FLUORIDE 2 NAPROXEN SODIUM DS 1
MULTI-VITAMIN-FLUOR-IRON 2 NARATRIPTAN 2 QL
MULTIVITAMIN-IRON-FLUORIDE 2 NARATRIPTAN HCL 2 QL
MULTIVITAMINS CHEWABLES TABLET 2 NARCAN 4 MG NASAL SPRAY 3
MULTIVITAMINS W-FLUORIDE-IRON 2 NATAZIA 4
MULTIVITAMINS WITH FLUORIDE 2 NATEGLINIDE 2
MULTIVIT-FLUOR 0.25 MG TAB CHW 2 NATURE-THROID 1
MULTIVIT-FLUOR 0.25 MG/ML DROP 2 NEBUPENT 4
MULTIVIT-FLUOR 0.5 MG TAB CHEW 2 NEBUSAL 3% VIAL 2
MULTIVIT-FLUOR 0.5 MG/ML DROP 2 NECON 1
MULTIVIT-FLUORIDE 1 MG TAB CHW 2 NEFAZODONE HCL 2
MULTIVIT-FLUOR-IRON 0.25 MG/ML 2 NEOMYCIN SULFATE 2
MULTIVIT-IRON-FL 0.25 MG/ML 2 NEOMYCIN-BACITRACIN-POLY-HC 2
MUPIROCIN 2 NEOMYCIN-BACITRACIN-POLYMYXIN 2
MVW COMPLETE FORMLTN PEDIATRIC 2 NEOMYCIN-POLYMYXIN B 2
MVW COMPLETE FORMULATION D3000 2 NEOMYCIN-POLYMYXIN-DEXAMETH 2
MVW COMPLETE FORMULATION D5000 2 NEOMYCIN-POLYMYXIN-GRAMICIDIN 2
MVW COMPLETE FORMULTN MULTIVIT 2 NEOMYCIN-POLYMYXIN-HC 2
MY WAY 4 NEOMYCIN-POLYMYXIN-HYDROCORT 2
MYCOPHENOLATE 200 MG/ML SUSP 2 NEO-POLYCIN 2
MYCOPHENOLATE 250 MG CAPSULE 2 NEO-POLYCIN HC 2
MYCOPHENOLATE 500 MG TABLET 2 NEUAC GEL 2
MYCOPHENOLIC ACID 2 NEVIRAPINE 2
MYNATAL 1 NEVIRAPINE ER 2
MYNATAL ADVANCE 1 NEWGEN 1
MYNATAL PLUS 1 NEXT CHOICE ONE DOSE 4
MYNATAL-Z 1 NIACIN ER 2
MYNATE 90 PLUS 1 NICARDIPINE 20 MG CAPSULE 2
MYORISAN 2 QL NICARDIPINE 30 MG CAPSULE 2
MYZILRA 1 NIFEDICAL XL 2
NABUMETONE 2 NIFEDIPINE 2
NADOLOL 1 NIFEDIPINE ER 2
NADOLOL-BENDROFLUMETHIAZIDE 2 NIKKI 1
NAFTIFINE HCL 2 NILUTAMIDE 2
NALOXONE 0.4 MG/ML CARPUJECT 2 NIMODIPINE 2
NALOXONE 2 MG/2 ML SYRINGE 2 NISOLDIPINE 2 QL
NALTREXONE HCL 2 NITRO-BID 2
NAPROXEN 125 MG/5 ML SUSPEN 2 NITRO-DUR 4
NAPROXEN 250 MG TABLET 1 NITROFURANTOIN 2
NAPROXEN 375 MG TABLET 1 NITROFURANTOIN MONO-MACRO 2
NAPROXEN 500 MG KIT 1 NITROGLYCERIN 0.3 MG TABLET SL 2
NAPROXEN 500 MG TABLET 1 NITROGLYCERIN 0.4 MG TABLET SL 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
212019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
NITROGLYCERIN 0.6 MG TABLET SL 2 NYSTATIN 150,000,000 UNITS PWD 2
NITROGLYCERIN 400 MCG SPRAY 2 NYSTATIN 500,000 UNIT ORAL TAB 2
NITROGLYCERIN ER 2.5 MG CAP 2 NYSTATIN 500,000 UNIT/5 ML SUS 2
NITROGLYCERIN ER 6.5 MG CAP 2 NYSTATIN 500,000,000 UNITS PWD 2
NITROGLYCERIN ER 9 MG CAPSULE 2 NYSTATIN-TRIAMCINOLONE 1
NITROGLYCERIN LINGUAL 0.4 MG 2 NYSTOP 2
NITROGLYCERIN PATCH 2 OBSTETRIX DHA 1
NITRO-TIME 2 OBSTETRIX ONE 1
NIVA-PLUS 1 O-CAL FA 4
NIZATIDINE 15 MG/ML SOLUTION 2 O-CAL PRENATAL 4
NIZATIDINE 150 MG CAPSULE 1 OCELLA 1
NIZATIDINE 300 MG CAPSULE 1 OCTREOTIDE ACETATE 2 PA
NOLIX 2 ODEFSEY 3
NORA-BE 1 OFLOXACIN 2
NORETHIND-ETH ESTRAD 0.5-2.5 2 OGESTREL 1
NORETHIND-ETH ESTRAD 1-0.02 MG 1 OKEBO 2
NORETHINDRONE 1 OLANZAPINE 10 MG TABLET 2
NORETHINDRONE ACETATE 2 OLANZAPINE 15 MG TABLET 2
NORETHIN-ETH ESTRAD 1 MG-5 MCG 2 OLANZAPINE 2.5 MG TABLET 2
NORETHIN-ETH ESTRA-FERROUS FUM 1 OLANZAPINE 20 MG TABLET 2
NORGESTIMATE-ETHINYL ESTRADIOL 1 OLANZAPINE 5 MG TABLET 2
NORINYL 1-35 4 OLANZAPINE 7.5 MG TABLET 2
NORLYDA 1 OLANZAPINE ODT 2
NORLYROC 1 OLANZAPINE-FLUOXETINE HCL 2
NORPACE CR 4 OLMESARTAN MEDOXOMIL 2
NOR-Q-D 4 OLMESARTAN-AMLODIPINE-HCTZ 2
NORTREL 1 OLMESARTAN-HYDROCHLOROTHIAZIDE 2
NORTRIPTYLINE 10 MG/5 ML SOLN 2 OLOPATADINE HCL 2
NORTRIPTYLINE HCL 10 MG CAP 1 OMEGA-3 ACID ETHYL ESTERS 2
NORTRIPTYLINE HCL 25 MG CAP 1 OMEPRAZOLE DR 10 MG CAPSULE 2 QL
NORTRIPTYLINE HCL 50 MG CAP 1 OMEPRAZOLE DR 20 MG CAPSULE 2 QL
NORTRIPTYLINE HCL 75 MG CAP 1 OMEPRAZOLE DR 40 MG CAPSULE 2 QL
NORVIR 3 ONDANSETRON HCL 2
NOVOFINE 30G X 1/3" NEEDLES 3 ONDANSETRON ODT 2
NOVOFINE 32G NEEDLES 3 ONETOUCH DELICA 30G LANCETS 3
NOVOFINE AUTOCOVER 30G NEEDLE 3 ONETOUCH DELICA 33G LANCETS 3
NOVOFINE PLUS PEN NDL 32GX1/6" 3 ONETOUCH DELICA LANCING DEV 3
NOVOTWIST NEEDLE 30G 8MM 3 ONETOUCH SURESOFT 18G LANC DEV 3
NOVOTWIST NEEDLE 32G 5MM 3 ONETOUCH SURESOFT 21G LANC DEV 3
NP THYROID 1 ONETOUCH SURESOFT 28G LANC DEV 3
NULEV 1 ONETOUCH ULTRA BLUE TEST STRP 3
NUVARING 3 ONETOUCH ULTRA2 1
NYAMYC 2 ONETOUCH ULTRAMINI 1
NYATA 100,000 UNIT/GM POWDER 2 ONETOUCH ULTRASOFT LANCETS 3
NYSTATIN 100,000 UNIT/GM CREAM 1 ONETOUCH VERIO FLEX 1
NYSTATIN 100,000 UNIT/GM POWD 2 ONETOUCH VERIO IQ 1
NYSTATIN 100,000 UNIT/ML SUSP 2 ONETOUCH VERIO METER SYSTEM 1
NYSTATIN 100,000 UNITS/GM OINT 1 ONETOUCH VERIO TEST STRIP 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
222019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
ONGLYZA 3 QL PASER 4
OPCICON ONE-STEP 1 PEG 3350-ELECTROLYTE 2
OPIUM TINCTURE 2 PEG-3350 AND ELECTROLYTES 2
ORALONE 2 PEG-3350 WITH FLAVOR PACKS 2
ORPHENADRINE ER 100 MG TABLET 2 PEGANONE 4
ORSYTHIA 1 PEG-PREP 2
ORTHO MICRONOR 4 PENICILLIN V POTASSIUM 1
ORTHO TRI-CYCLEN 4 PENTAZOCINE-NALOXONE HCL 2
ORTHO TRI-CYCLEN LO 4 PENTOXIFYLLINE 2
ORTHO-CYCLEN 4 PERINDOPRIL ERBUMINE 2
ORTHO-NOVUM 4 PERMETHRIN 5% CREAM 2
OSCIMIN 0.125 MG ODT 1 PERPHENAZINE 2
OSCIMIN 0.125 MG TABLET 2 PERPHENAZINE-AMITRIPTYLINE 2
OSCIMIN SL 1 PHENADOZ 2
OSCIMIN SR 2 PHENAZOPYRIDINE HCL 1
OSELTAMIVIR PHOSPHATE 2 QL PHENELZINE SULFATE 2
OVCON-35 1 PHENOBARBITAL 100 MG TABLET 2
OXANDROLONE 2 PA PHENOBARBITAL 15 MG TABLET 2
OXAPROZIN 2 PHENOBARBITAL 16.2 MG TABLET 2
OXAZEPAM 2 PHENOBARBITAL 20 MG/5 ML ELIX 2
OXCARBAZEPINE 2 PHENOBARBITAL 20 MG/5 ML SOLN 2
OXICONAZOLE NITRATE 2 PHENOBARBITAL 30 MG TABLET 2
OXYBUTYNIN 5 MG TABLET 1 PHENOBARBITAL 32.4 MG TABLET 2
OXYBUTYNIN 5 MG/5 ML SYRUP 2 PHENOBARBITAL 60 MG TABLET 2
OXYBUTYNIN CHLORIDE ER 2 PHENOBARBITAL 64.8 MG TABLET 2
OXYCODON-ACETAMINOPHEN 2.5-325 2 PHENOBARBITAL 97.2 MG TABLET 2
OXYCODON-ACETAMINOPHEN 7.5-325 2 PHENOXYBENZAMINE HCL 10 MG CAP 2
OXYCODONE HCL 2 PHENYLEPHRINE 10% EYE DROPS 2
OXYCODONE HCL-ASPIRIN 2 PHENYLEPHRINE 2.5% EYE DROP 2
OXYCODONE HCL-IBUPROFEN 2 PHENYTOIN 2
OXYCODONE-ACETAMINOPHEN 10-325 2 PHENYTOIN SODIUM EXTENDED 2
OXYCODONE-ACETAMINOPHEN 5-325 2 PHILITH 1
OXYMORPHONE HCL 2 PHOSPHA 250 NEUTRAL 2
OXYMORPHONE HCL ER 2 QL PHOSPHASAL 2
PACERONE 200 MG TABLET 2 PHRENILIN FORTE 2
PALIPERIDONE ER 2 PHYTONADIONE 5 MG TABLET 2
PANTOPRAZOLE SOD DR 20 MG TAB 2 QL PILOCARPINE HCL 2
PANTOPRAZOLE SOD DR 40 MG TAB 2 QL PIMOZIDE 2
PAREGORIC 2 PIMTREA 1
PARICALCITOL 1 MCG CAPSULE 2 PINDOLOL 2
PARICALCITOL 2 MCG CAPSULE 2 PIOGLITAZONE HCL 2
PARICALCITOL 4 MCG CAPSULE 2 PIOGLITAZONE-GLIMEPIRIDE 2
PAROEX 2 PIOGLITAZONE-METFORMIN 2
PAROMOMYCIN SULFATE 2 PIRMELLA 1
PAROXETINE CR 2 QL PIROXICAM 2
PAROXETINE ER 2 QL PLAN B ONE-STEP 4
PAROXETINE HCL 1 QL PNV 29-1 1
Please visit Cigna.com/ifp-drug-list to see a complete listing.
232019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
PNV OB+DHA 1 PREFEST 2
PNV-DHA 1 PRENA1 TRUE 1
PNV-DHA + DOCUSATE 1 PRENAISSANCE 1
PNV-FERROUS FUMARATE-DOCU-FA 1 PRENAISSANCE NEXT 1
PNV-OMEGA 1 PRENAISSANCE PLUS 1
PNV-SELECT 1 PRENATAL 19 1
PNV-VP-U 1 PRENATAL LOW IRON 1
PODOFILOX 2 PRENATAL PLUS 1
POLYCIN 2 PRENATAL PLUS-DHA COMBO PACK 1
POLYETHYLENE GLYCOL 3350 POWD 2 PRENATAL VITAMIN PLUS LOW IRON 1
POLYMYXIN B SUL-TRIMETHOPRIM 2 PRENATAL-U 1
PORTIA 1 PREPLUS 1
POTASS CIT-SOD CIT-CITRIC ACID 2 PRETAB 1
POTASSIUM CITRATE ER 2 PREVALITE 2
POTASSIUM CITRATE-CITRIC ACID 2 PREVIFEM 1
POTASSIUM CL 10% (20 MEQ/15 ML 2 PREZCOBIX 3
POTASSIUM CL 10% (40 MEQ/30 ML 2 PREZISTA 3
POTASSIUM CL 20 MEQ PACKET 2 PRIFTIN 4
POTASSIUM CL 20% (40 MEQ/15 ML 2 PRIMAQUINE 2
POTASSIUM CL 25 MEQ TAB EFF 2 PRIMIDONE 2
POTASSIUM CL ER 10 MEQ CAPSULE 2 PRIMLEV 2
POTASSIUM CL ER 10 MEQ TABLET 2 PRO COMFORT ALCOHOL PADS 3
POTASSIUM CL ER 20 MEQ TABLET 2 PROBENECID 2
POTASSIUM CL ER 8 MEQ CAPSULE 2 PROBENECID-COLCHICINE 2
POTASSIUM CL ER 8 MEQ TABLET 2 PROCENTRA 2
PR BENZOYL PEROXIDE 2 PROCHLORPERAZINE 2
PR BENZOYL PEROXIDE 7% WASH 2 PROCHLORPERAZINE MALEATE 2
PR NATAL 400 1 PROCTO-MED HC 2
PR NATAL 400 EC 1 PROCTO-PAK 2
PR NATAL 430 1 PROCTOSOL-HC 2
PR NATAL 430 EC 1 PROCTOZONE-HC 2
PRAMCORT 2 PROFENO 2
PRAMIPEXOLE DIHYDROCHLORIDE 2 PROGESTERONE 100 MG CAPSULE 2
PRAMIPEXOLE ER 2 PROGESTERONE 200 MG CAPSULE 2
PRASUGREL HCL 2 PROGLYCEM 4
PRAVASTATIN SODIUM 1 PROMETHAZINE 12.5 MG SUPPOS 2
PRAZIQUANTEL 2 PROMETHAZINE 12.5 MG TABLET 2
PRAZOSIN HCL 2 PROMETHAZINE 25 MG SUPPOSITORY 2
PREDNICARBATE 2 PROMETHAZINE 25 MG TABLET 2
PREDNISOLONE 2 PROMETHAZINE 50 MG SUPPOSITORY 2
PREDNISOLONE 15 MG/5 ML SOLN 2 PROMETHAZINE 50 MG TABLET 2
PREDNISOLONE 5 MG/5 ML SOLN 2 PROMETHAZINE 6.25 MG/5 ML SOLN 2
PREDNISOLONE ACETATE 2 PROMETHAZINE 6.25 MG/5 ML SYRP 2
PREDNISOLONE SOD 1% EYE DROP 2 PROMETHAZINE VC 2
PREDNISOLONE SOD PH 25 MG/5 ML 2 PROMETHAZINE VC-CODEINE 2
PREDNISOLONE SODIUM PHOS ODT 2 PROMETHAZINE-CODEINE 2
PREDNISONE 2 PROMETHAZINE-DM 2
PREDNISONE INTENSOL 2 PROMETHAZINE-PHENYLEPH-CODEINE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
242019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
PROMETHAZINE-PHENYLEPHRINE 2 RENAGEL 4
PROMETHEGAN 2 REPAGLINIDE 2
PROPAFENONE HCL 2 REPAGLINIDE-METFORMIN HCL 2
PROPAFENONE HCL ER 2 REPREXAIN 2
PROPANTHELINE BROMIDE 2 REYATAZ 3
PROPARACAINE 0.5% EYE DROPS 2 RIBASPHERE 2
PROPRANOLOL 10 MG TABLET 2 RIBAVIRIN 200 MG CAPSULE 2
PROPRANOLOL 20 MG TABLET 2 RIBAVIRIN 200 MG TABLET 2
PROPRANOLOL 20 MG/5 ML SOLN 2 RIFABUTIN 2
PROPRANOLOL 40 MG TABLET 2 RIFAMATE 4
PROPRANOLOL 40 MG/5 ML SOLN 2 RIFAMPIN 150 MG CAPSULE 2
PROPRANOLOL 60 MG TABLET 2 RIFAMPIN 300 MG CAPSULE 2
PROPRANOLOL 80 MG TABLET 2 RILUZOLE 2
PROPRANOLOL HCL ER 2 RIMANTADINE HCL 2
PROPRANOLOL-HYDROCHLOROTHIAZID 2 RISEDRONATE SODIUM 2
PROPYLTHIOURACIL 2 RISEDRONATE SODIUM DR 2
PROTRIPTYLINE HCL 2 RISPERIDONE 2
PRUDOXIN 2 RISPERIDONE ODT 2
PSORCON 2 RITONAVIR 2
PULMOSAL 2 RIVASTIGMINE 2
PYRAZINAMIDE 2 RIVELSA 1
PYRIDOSTIGMINE BROMIDE 2 RIZATRIPTAN 2 QL
PYRIDOSTIGMINE BROMIDE ER 2 R-NATAL OB 1
QUARTETTE 4 ROPINIROLE ER 2
QUASENSE 1 ROPINIROLE HCL 2
QUAZEPAM 15 MG TABLET 2 ROSADAN 0.75% CREAM 2
QUETIAPINE FUMARATE 2 ROSADAN 0.75% GEL 2
QUETIAPINE FUMARATE ER 2 ROSUVASTATIN CALCIUM 2
QUINAPRIL HCL 2 ROWEEPRA 2
QUINAPRIL-HYDROCHLOROTHIAZIDE 2 ROWEEPRA XR 2
QUINIDINE GLUC ER 324 MG TAB 2 RULAVITE DHA 1
QUINIDINE SULFATE 2 SAFYRAL 4
QUININE SULFATE 2 SALICYLIC ACID 27.5% LIQUID 2
RABEPRAZOLE SODIUM 2 QL SALSALATE 2
RAJANI 1 SAPHRIS 4 ST, QL
RALOXIFENE HCL 2 SCOPOLAMINE 2
RAMIPRIL 2 SEASONIQUE 4
RANITIDINE 15 MG/ML SYRUP 2 SECONAL SODIUM 2
RANITIDINE 150 MG CAPSULE 1 SELEGILINE HCL 2
RANITIDINE 150 MG TABLET 1 SELENIUM SULFIDE 2.25% SHAMPOO 2
RANITIDINE 150 MG/10 ML SYRUP 2 SELENIUM SULFIDE 2.5% LOTION 2
RANITIDINE 300 MG CAPSULE 1 SE-NATAL 19 1
RANITIDINE 300 MG TABLET 1 SEREVENT DISKUS 3
RASAGILINE MESYLATE 2 SERTRALINE 20 MG/ML ORAL CONC 2 QL
RECLIPSEN 1 SERTRALINE 20 MG/ML ORAL SOLN 2 QL
RELENZA 4 QL SERTRALINE HCL 100 MG TABLET 1 QL
RELISTOR 4 PA SERTRALINE HCL 25 MG TABLET 1 QL
RELNATE DHA 1 SERTRALINE HCL 50 MG TABLET 1 QL
Please visit Cigna.com/ifp-drug-list to see a complete listing.
252019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
SETLAKIN 1 SULFAMETHOXAZOLE-TMP SS TABLET 2
SEVELAMER CARBONATE 800 MG TAB 2 SULFAMETHOXAZOLE-TMP SUSP 2
SF 2 SULFASALAZINE 2
SF 5000 PLUS 2 SULFASALAZINE DR 2
SHAROBEL 1 SULINDAC 2
SILDENAFIL 2 PA SUMATRIPTAN 2 QL
SILVER NITRATE 2 SUMATRIPTAN SUCCINATE 2 QL
SILVER SULFADIAZINE 2 SURE COMFORT ALCOHOL 3
SIMVASTATIN 10 MG TABLET 1 SURE-PREP ALCOHOL PREP PADS 3
SIMVASTATIN 20 MG TABLET 1 SUSTIVA 3
SIMVASTATIN 40 MG TABLET 1 SYEDA 1
SIMVASTATIN 5 MG TABLET 1 SYMAX 1
SIMVASTATIN 80 MG TABLET 1 QL SYMAX-SL 1
SINGLE USE SWAB 3 SYMAX-SR 2
SIROLIMUS 2 SYNTHROID 4
SIRTURO 4 PA TABLOID 4
SODIUM CHLORIDE 0.9% INHAL VL 2 TACROLIMUS 2
SODIUM CHLORIDE 0.9% IRRIG. 2 TAKE ACTION 4
SODIUM CHLORIDE 10% VIAL 2 TAMIFLU 30 MG CAPSULE 4 QL
SODIUM CHLORIDE 3% VIAL 2 TAMIFLU 45 MG CAPSULE 4 QL
SODIUM CHLORIDE 7% VIAL 2 TAMIFLU 75 MG CAPSULE 4 QL
SODIUM CITRATE-CITRIC ACID 2 TAMOXIFEN CITRATE 2
SODIUM FLUORIDE 2 TAMSULOSIN HCL 2
SODIUM PHENYLBUTYRATE 2 TARINA FE 1
SODIUM POLYSTYRENE SULFONATE 2 TARON-C DHA 1
SOLOXIDE 2 TARON-PREX PRENATAL 1
SOTALOL 1 TAYTULLA 3
SOTALOL AF 1 TAZTIA XT 2
SPINOSAD 2 TELMISARTAN 2
SPIRONOLACTONE 2 TELMISARTAN-AMLODIPINE 2
SPIRONOLACTONE-HCTZ 2 TELMISARTAN-HYDROCHLOROTHIAZID 2
SPRINTEC 1 TEMAZEPAM 2
SPS 2 TEMOZOLOMIDE 4 PA
SRONYX 1 TENCON 2
SSKI 4 TENOFOVIR DISOPROXIL FUMARATE 2
STAVUDINE 2 TERAZOSIN HCL 1
STERILE WATER FOR IRRIGATION 2 TERBINAFINE HCL 1
STRIBILD 3 TERBUTALINE SULFATE 2.5 MG TAB 2
STRONG IODINE 2 TERBUTALINE SULFATE 5 MG TAB 2
SUBVENITE 2 TERCONAZOLE 2
SUBVENITE (BLUE) 2 TESTOSTERONE 10 MG GEL PUMP 2 QL
SUBVENITE (GREEN) 2 TESTOSTERONE 12.5 MG/1.25 GRAM 2 QL
SUBVENITE (ORANGE) 2 TESTOSTERONE 25 MG/2.5 GM PKT 2 QL
SUCRALFATE 2 TESTOSTERONE 50 MG/5 GRAM GEL 2 QL
SULFACETAMIDE SODIUM 2 TESTOSTERONE 50 MG/5 GRAM PKT 2 QL
SULFACETAMIDE-PREDNISOLONE 2 TESTOSTERONE CYPIONATE 2
SULFADIAZINE 2 TESTOSTERONE ENANTHATE 2
SULFAMETHOXAZOLE-TMP DS TABLET 2 TETCAINE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
262019 Cigna Rx Essential Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
TETRABENAZINE 2 PA TRANDOLAPRIL-VERAPAMIL ER 2
TETRACAINE 0.5% EYE DROPS 2 TRANEXAMIC ACID 650 MG TABLET 2
TETRACAINE 0.5% STERI-UNIT SOL 2 TRANYLCYPROMINE SULFATE 2
TETRACYCLINE HCL 1 TRAVATAN Z 3
THEOCHRON 2 TRAZODONE HCL 1
THEOPHYLLINE 2 TRECATOR 4
THEOPHYLLINE ANHYDROUS 2 TRETINOIN 0.01% GEL 2 AGE
THIORIDAZINE HCL 2 TRETINOIN 0.025% CREAM 2 AGE
THIOTHIXENE 2 TRETINOIN 0.025% GEL 2 AGE
THRIVITE 19 1 TRETINOIN 0.05% CREAM 2 AGE
THYROID 1 TRETINOIN 0.05% GEL 2 AGE
TIAGABINE HCL 2 TRETINOIN 0.1% CREAM 2 AGE
TICLOPIDINE HCL 2 TRETINOIN 10 MG CAPSULE 4 PA
TILIA FE 1 TRETINOIN MICROSPHERE 2 AGE
TIMOLOL 0.25% GEL-SOLUTION 2 TRI FEMYNOR 1
TIMOLOL 0.25% GFS GEL-SOLUTION 2 TRIADVANCE 1
TIMOLOL 0.5% GEL-SOLUTION 2 TRIAMCINOLONE 0.025% CREAM 2
TIMOLOL 0.5% GFS GEL-SOLUTION 2 TRIAMCINOLONE 0.025% LOTION 2
TIMOLOL MALEATE 0.25% EYE DROP 2 TRIAMCINOLONE 0.025% OINT 2
TIMOLOL MALEATE 0.5% EYE DROPS 2 TRIAMCINOLONE 0.1% CREAM 2
TIMOLOL MALEATE 10 MG TABLET 2 TRIAMCINOLONE 0.1% LOTION 2
TIMOLOL MALEATE 20 MG TABLET 2 TRIAMCINOLONE 0.1% OINTMENT 2
TIMOLOL MALEATE 5 MG TABLET 2 TRIAMCINOLONE 0.1% PASTE 2
TINIDAZOLE 2 TRIAMCINOLONE 0.147 MG/G SPRAY 2
TIVICAY 3 TRIAMCINOLONE 0.5% CREAM 2
TIZANIDINE HCL 2 TRIAMCINOLONE 0.5% OINTMENT 2
TL-SELECT 1 TRIAMTERENE-HYDROCHLOROTHIAZID 2
TOBRAMYCIN 2 TRIAZOLAM 2
TOBRAMYCIN-DEXAMETHASONE 2 TRICITRATES 2
TOLAZAMIDE 2 TRIDERM 2
TOLBUTAMIDE 2 TRI-ESTARYLLA 1
TOLCAPONE 2 TRIFLUOPERAZINE HCL 2
TOLMETIN SODIUM 2 TRIFLURIDINE 2
TOLTERODINE TARTRATE 2 TRIHEXYPHENIDYL HCL 2
TOLTERODINE TARTRATE ER 2 TRIKLO 2
TOPIRAMATE 2 TRI-LEGEST FE 1
TOPIRAMATE ER 2 TRI-LINYAH 1
TORSEMIDE 2 TRI-LO-ESTARYLLA 1
TRAMADOL ER 100 MG TABLET 2 QL TRI-LO-MARZIA 1
TRAMADOL ER 200 MG TABLET 2 QL TRI-LO-SPRINTEC 1
TRAMADOL ER 300 MG TABLET 2 QL TRILYTE WITH FLAVOR PACKETS 2
TRAMADOL HCL 2 QL TRIMETHOBENZAMIDE HCL 2
TRAMADOL HCL ER 100 MG TABLET 2 QL TRIMETHOPRIM 2
TRAMADOL HCL ER 150 MG CAPSULE 2 QL TRI-MILI 1
TRAMADOL HCL ER 200 MG TABLET 2 QL TRIMIPRAMINE MALEATE 2
TRAMADOL HCL ER 300 MG TABLET 2 QL TRINATAL GT 1
TRAMADOL HCL-ACETAMINOPHEN 2 QL TRINATAL RX 1 1
TRANDOLAPRIL 2 TRINESSA 1
Please visit Cigna.com/ifp-drug-list to see a complete listing.
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